What's in a name?

An "isolated" side-room, but only by name. The transparent window panes and the open door do little to seperate this patient from the rest of the Intensive Care Unit. We sidle in one by one, until there are about a dozen of us around the bed. The discussions begin.
A dark, vertical line across her abdomen confirms that she was pregnant until three days ago. Having lapsed into a coma shortly after delivering, she has yet to see her baby. She was admitted to the hospital two days earlier, complaining of fever, headache and generalised aches. Now she is unconscious, and bleeding. In fact, she hasn't stopped bleeding since giving birth. 15 units of blood, three times her circulating volume, have been transfused. But we are only buying time, and at a very high cost.
The problem with dengue is that it can make you bleed for a week, sometimes two. That's an awful lot of blood. It may well be that she's unconscious because of a bleed in her brain as well, but an ambulance transfer to a scanner, when you're connected to a ventilator and being transfused, is not a feasible option. It's far from obvious what the next step should be.

Out of the two crossed conversations taking place, I try to block out the Vietnamese and concentrate on the English. My mind invariably drifts back to the fascinating sounds and intonations of the Vietnamese, which try as I might I cannot yet reproduce; the only word I can make out is "dengue". Like the mosquito-borne virus it describes, the word has spread from the African continent (dinga, Swahili for "cramp") to most of the tropics. Some say that the Swahili origin was influenced in the West Indies by the Spanish dengue, meaning "prudent" - a reference to the gait adopted by sufferers. The muscle and joint pains which account for this gait have also earned dengue the nickname "break-bone fever".
Today dengue accounts for 50 to 100 million infections every year. Repeated infection can lead to life-threatening dengue haemorrhagic fever - while our patient only has a milder form of this bleeding disorder, the coincidence with her labour could yet prove fatal. There is no cure for dengue: all we can hope to achieve is prevention, hopefully through vaccination.

If and when dengue becomes a rare disease of Ancient Times, its name will perhaps serve to remind us of the suffering it caused for centuries.

Progress towards a dengue vaccine (Webster, Farrar and Rowland-Jones)

All Hail Penicillium

We are all familiar with the story of Alexander Fleming, returning from holiday in 1928 to discover his S. aureus culture plates had been contaminated. An assistant, carelessly, had left a window open in the laboratory; Penicillium chrysogenum, no doubt sensing an opportunity to become famous, went on a rampage, killing countless bacteria. Fleming realised what had happened and since then penicillin has saved innumerable lives.
You might not know that P. chrysogenum has an older cousin who first arrived on the scene long before that. Around a thousand years ago, a shepherd abandoned his cheese sandwich in a cave, to take a second look at a young lady who was passing by. He returned later (cheese sandwiches being in short supply back then) to find his snack had become mouldy. Roquefort was born, thanks to the best efforts of P. roqueforti. I'll spare you the similarly authenticated tales of how Camembert and Gorgonzola came into being. It can be humbling to realise how much we owe to a family of moulds.

However, there is a dark sheep in this family.

The patient lies quietly in the HIV ward, which is aptly-named. He is staring at the ceiling in an isolated, six bed bay. We interrupt his thoughts. There are only three of us, which probably makes a welcome change for patients who are used to more than a dozen doctors and nurses on each ward round. He's known to have HIV, but he isn't receiving anti-retroviral drugs. For the last month he's been tired, coughing, losing weight, feverish. His chest X-ray is normal. He's very anaemic, and his liver and spleen are massively enlarged. He's had frequent nose-bleeds and he's obviously uncomfortable while we examine him. An unusual rash, reminiscent of chickenpox, covers him from head to toe.
The Consultant picks my brains: how can I explain all these findings? I'm quite proud to have come up with a half-dozen suggestions, even if they turn out to all be wrong. Which they do. I begin to plead ignorance. "Penicillium marneffei", I'm told. A fungus present only in South-East Asia which causes disease only in the immuno-compromised. I had strategically decided not to learn about it for finals, but it seems that the Penicillium family is greater than I had ever suspected.
A course of itraconazole and amphotericin B will cure him of his penicilliosis soon enough, but he'll still be left with the HIV. And before we curse the virus, it's worth noting that it has quickly become one of the most important tools in molecular biology today. These microbes just can't decide whether to be good or bad.

Information on P.marneffei

The Malaria Ward

No flip-flops, shorts or vests; white coats are compulsory. Those were the rules explained to me before my 1st ward round on the Malaria ward. A short walk in the shade of some palm trees takes us from the OUCRU (Oxford University Clinical Research Unit) to the ward. The last 25 metres are not sheltered from the sun, and it makes us pick up the pace. The shade of the malaria ward is most welcome, but the heat is still there. There's a small oasis of cool in the air-conditionned doctors' office, where we wait for everyone to assemble. To get there, we have to single-file past two beds which lie in the corridor, each one carrying a very tired-looking patient.
The ward's name is misleading: the vast majority of the patients on this ward (13 in total today) don't have malaria. The name is historical, as this was once the ward where all malaria cases were treated. There was a time when malaria was a great burden for Vietnam, as it still is in much of South-East Asia. In 1991, there were nearly 2 million cases and more than 4,500 deaths from malaria in this country. Since then, thanks to a massive commitment from the Vietnamese Government, and significant financial assistance from the World Bank, Vietnam has succeeded in almost eradicating the disease. By 2003, cases were down to 37,416 and there were only 50 deaths.
Based on this morning's round, a more suitable name would be the Meningitis ward. Bacterial, TB, viral; even eosinophilic, a new one for me. The Vietnamese doctors summarise the case in English, for the benefit of the 2 or 3 members of the round who don't speak Vietnamese. I listen carefully, trying to block out the noise of the large fans on the ceiling. Ceftriaxone, vancomycin, ampicillin - some rebel patients still refuse to get better. It's difficult when a CT scan implies a drive through the city in an ambulance; in a city like Saigon, the drive itself could prove more dangerous than the meningitis....
Having seen a single case of malaria, we leave the ward and enter the ICU. In a side-room, a young man lies spread-eagle on a bed, the haemofiltration machine doing its best to rid his blood of the parasites within it. "This patient spent many years in a malaria-endemic region of Vietnam", we are told. Those tend to be the more rural and forested parts of the country. "His parasitaemia level is nearly 10%". That's very high; I try to remember what the management for severe malaria is. "We think he has brain death".

And there it is, malaria's latest victim. Perhaps the name of the ward serves as a useful reminder.


Barat, LM. "Four malaria success stories: how malaria burden was successfully reduced in Brazil, Eritrea, India, and Vietnam." Am J Trop Med Hyg (2006); 74(1):12-6.

The end of infectious diseases?

In 1965, Dr William Stewart was appointed US Surgeon General. These were challenging times in Public Health. A year earlier, Stewart's wonderfully-named predecessor, Luther Leonidas Terry, had overseen the publication of a report on the links between smoking and lung cancer. This in turn followed a landmark report published in the UK in 1962, which stated clearly that smoking was a cause of lung cancer and bronchitis. These were the first steps in a long struggle between public health doctors and the tobacco industry, a fight which goes on today despite the advantage having clearly shifted from the latter to the former camp.
In 1967, William Stewart, realising that chronic diseases such as cancer, cardiovascular disease and diabetes would soon take over as the leading causes of mortality, infamously stated that it was "time to close the book on infectious disease" (well, maybe he didn't; some claim he was misquoted - perhaps he mis-spoke?). To be fair to him, antibiotics had recently revolutionised the treatment of communicable diseases, and immunisation programs were gathering pace in most developed countries. Polio was on the way out. Polio! There was obviously cause for optimism.
Well, the 1960s weren't just tough in the corridors of the Center for Disease Control and Prevention. The magnitude of the conflict in Vietnam was becoming plain for all to see - Stewart was actually under a lot of pressure to reduce public health expenditure because of the cost of the war. Yet Vietnam also offered good evidence that the book of infectious diseases was nowhere near its final chapter. In 1965, Cho Quan hospital in Saigon was building a new contagious diseases ward and a new operating room for leprosy patients. The hospital was already over 100 years old by then, and has kept on growing since - in 1979, it became the first hospital in Vietnam specialising in infectious diseases. Today it is called the Centre for Tropical Diseases, and it lies just outside the centre of Ho Chi Minh City.
A brief meeting this morning with Dr Chinh, Director of the hospital, reminds me that while infectious diseases seem quite small-print when you are in Oxford, they are very much the bread and butter of medicine in many parts of the world. At any one time there are at least 10 patients in the hospital suffering from tetanus. Then there's the TB, the dengue, the HIV. Oh, and malaria's thinking of making a comeback in Vietnam.
They're nowhere near extinction. Infectious diseases are here to stay and may well become an even greater problem as climate change exerts its effects. I expect the next few weeks will help drive the point home for me. If there are any interesting stories along the way (and I'm sure there will be), I'll let you know.